The Human Factor: The critical importance of communication and - PDF document

10/20/2018 The Human Factor: The critical importance of communication and effective teamwork in providing excellent care . Anna K. Meyer, MD,FAAP, FACS Associate Professor Coach ‐ UCSF School of Medicine Facilitator, UCSF Center for Enhancement of Communication in Healthcare Faculty in Training, Academy of Communication in Healthcare It’s Not About the Nail https://www.youtube.com/watch?v=-4EDhdAHrOg 1

10/20/2018 Objectives  Understand the evidence that supports effective communication approaches.  Identify techniques for developing a relationship-centered approach in both patient care and teamwork.  Inspire you to seek opportunities to develop more skills in communication.  Commit to practicing one skill in the next week. 4 10/20/2018 2

10/20/2018 5 10/20/2018 “Melissa Ho has an uncanny and special communication ability with children, especially ours. Our daughter feels so confident and happy after her visits.” 6 10/20/2018 3

10/20/2018 Communication as a Precise Skill  Communication is the most common “procedure” we perform • Audiology career: 60,000 – 130,000 encounters  Less training, observation, and feedback than technical training  Can be learned, improved, and perfected with deliberate practice + feedback “And” vs. “But"  “I know you would like to not wear hearing aids, BUT they are important to help you hear.”  “I heard you wanted to see fewer patients in a day, BUT our financial situation won’t allow us to cut your schedule back.”  “I know you would like to not wear hearing aids AND I would like to hear more about what is hard for you about wearing them.”  “I heard you wanted to see fewer patients in a day AND I would like to work with you on how to make your schedule more manageable.” 4

10/20/2018 Pairs Activity Exercise: Think of an activity or part of your life that you really enjoy. Person 1: I really enjoy X… Person 2: You really enjoy X, BUT … Person 1: I really enjoy X… Person 2: You really enjoy X, AND… Switch roles and repeat. 9 10/20/2018 What do Patients Say? The provider was incredible!! He communicates compassion & She treated me with professionalism. kindness and respect . She was very patient and ready to answer any concerns or questions. He listens with great care. After meeting with her I felt assured that we were working together. She truly listens to my concerns …I feel like she is the first doctor I can really trust . 5

10/20/2018 What Do Patients Say? so much technical information and didn’t even sit down no time to ask questions rushing She was not patient. Dismissive of my questions Curt, bordering on rude I don't hear well and sometimes I could not really hear what they said, but it wasn't too important. 6

10/20/2018 Dickson R et al. J Palliat Med. 2012. Dickson R et al. J Palliat Med. 2012. 7

10/20/2018 Enhanced communication  Better Patient Outcomes:  Improved symptom management  Adherence to recommendations and advice  Patient experience Matthias, et al. Communicating About Opioids for Chronic Pain. Eur J Pain, 2014; Levinson et al, Health Affairs 2010; Dwamena et al, Cochrane Database Syst Rev 2012; Hojat et al, Acad Med 2013; Kennedy et al, Pat Experience J 2014; Safran et al, J Fam Pract 1998; Stewart et al, J Fam Pract 2000; Swayden et al, Pt Ed and Counsel, 2012. Enhanced communication  Better Outcomes for Clinicians & Teams  Better meaning in work  Decreased provider burnout  Decreased medical malpractice  Better work environment  More effective teams  Improved care across differences Boissy et al, J Gen Intern Med, 2016; Levinson et al, Patient Educ Couns, 2013; Suchman, Med Care, 1993; Ambady, et al, Surgeon’s Tone of Voice, Surgery, 2002. 8

10/20/2018 Frustrations and Challenges What are the things that patients or colleagues say or do that:  Create challenges?  Lead to “heart sink” moments?  Keep you up at night? 17 10/20/2018 How Can We Improve? Relationship ‐ Centered Communication 10/20/2018 18 9

10/20/2018 Sitting down inc r eases per c eption of time spent…  80% of patients Ac tual and Per c eived T ime prefer for the of Pr ovider Inter ac tion provider to sit. 6 5.14 5  Sitting takes no ime in minutes.sec onds more time than 4 3.44 standing. 3 2  Patients perceive 1.28 1.04 40% longer time 1 T spent. 0 Physic ians Sitting Physic ians Standing Swayden KJ et al. “Effect of sitting vs. standing on perception of Time in minutes.seconds Actual Time provider time at bedside: A pilot study.” Patient Educ Couns 86(2) 2012:166 ‐ 171. Time in minutes.seconds Perceived time 19 …and per c eption of c ommunic ation impr oves • Patients report a more positive interaction (95% versus 61%). − Better understanding of their condition. T ype of Comments for Siting and − Provider viewed as Standing 95% more compassionate 100% and caring. 80% 61% − Encouraged patient 60% 39% questions. 40% − Answered all 20% 5% questions. 0% Positive Sit Negative Sit Positive Stand Negative Sit − Took time to listen. Comments Comments Comments Comments (n=19/ 20) (n=1/ 20) (n=11/ 18) (n=7/ 18) 20 10

10/20/2018 Eliciting a List of the Person’s Agenda Items  “Can you tell me what’s on your list to talk about today?”  Then ask, “ What else?”  Keep asking until until all concerns exhausted – before delving further  Negotiate what can be discussed that visit Marvel et al, JAMA 1999; Heritage et al, JGIM 2007 21 10/20/2018 Eliciting the Agenda Getting the LIST up front is more efficient….why?  Patients do not always state their “chief complaint” first.  “oh, by the way, I’ve also been feeling dizzy….” • reduces “doorknob” questions from 35% vs 15% 22 10/20/2018 11

10/20/2018 Example of Negotiating a List  Establish patient’s priorities: “Of the things you listed, what is more important to you address today”  State your perspective: “I’m most concerned about your fluctuating hearing loss. Like you, I’d like to retest your hearing today and begin to discuss hearing aid options. We will have to schedule the full hearing aid evaluation for another visit.” 23 10/20/2018 Listening: Aren’t We Opening Pandora’s Box? • How soon do providers interrupt patients after asking a question? 18-23 seconds • How long will a patient talk if uninterrupted? 90 seconds • What are the risks of not allowing person to tell their story? - Most important concerns won’t come out - 75% never finish what they were saying - Diagnosis difficulty 12

10/20/2018 Open/Deepen the Conversation  Begin with an open-ended request / question • “Tell me all about your experience with hearing loss.”  Listen attentively and silently  Resist the urge to jump to questions  Embrace the possibility of hearing more of their story • What IDEAS do you have about what has caused your hearing loss? • What CONCERNS do you have about your clinic schedule? • What EXPECTATIONS do you have for what the hearing aids will do for you? 25 10/20/2018 Before RCC  No teenager wants to show that they have hearing loss, BUT hearing aids will help you because…  But it can connect directly to your phone!  Here’s normal hearing, here’s your hearing...  Hearing aids are important because…  Excuses: • Mom never reinforces at home… • There’s only so much I can do… • Young people… 26 10/20/2018 13

10/20/2018 With RCC – Elicit perspectives using The Box (Ida Institute) No Hearing Aids Surgery Intervention Pros Don't have to Hear better at Hear better wear school. Get without using uncomfortable better grades. hearing hearing aids. devices. Cons Can't hear as Uncomfortable Potential well, academic fit and sound, complications performance despite many from surgery. poorer. attempts to make fit more comfortable. 27 10/20/2018 With RCC  “These are all great points you bring up. Based on this list you made, which option would you be most interested in learning more about?” • Surgery  “Wonderful! Let’s partner on that next. So that I have a better idea what we can discuss next, could you answer on a scale of 1 to 10 (1=not considering surgery; 10=desiring surgery immediately), where would you rate yourself?” • 6-7  “May I ask what would make your rating a 8-9?” • learning about more of the complications of surgery  Discussed with Dr. Meyer  follow-up with patient during HCC visit 28 10/20/2018 14

10/20/2018 SLOW PROCESS  Patient came back 6 months later and said she wanted to consider surgery over winter break. (transcanal endoscopic ear surgery)  In the meantime, for non-surgical ear, requested a hearing aid IF we could make it more invisible (CIC vs previous BTEs) 29 10/20/2018 Developing Teams by Relationship-Building  Work to know the people you work with as people  Asking open ended questions of team members  Arranging teambuilding time that focus on the work you do AND the people you are.  Tell us something about your name  Tell us all about your journey to being here in this room.  I’ve found that our work and our lives are influenced by our backgrounds and experiences, tell us about a part of your background that you have pride in and also a challenge you have faced.  Develop curiosity and use active listening when conflicts arise 30 Presentation Title and/or Sub Brand Name Here 10/20/2018 15